CLINICAL PROBLEMS IN ACUTE

ABDOMINAL PAIN

Dr. U Sein WinM.B.,B.S. (Ygn), M.Med.Sc.(Surgery)

Associate Professor/Consultant SurgeonDepartment of Surgery

Institute of Medicine 2, Yangon

ACUTE ABDOMEN

• A SUDDEN SEVERE ABDOMINAL PAIN THAT IS LESS THAN 24 HOURS IN DURATION. It is in many cases an emergent condition requiring urgent and specific diagnosis which may or may not require immediate surgical treatment.

• Abdominal pain of less than 1 week’s duration requiring admission to hospital which has not been previously investigated or treated.

To solve clinical problem in acute abdominal pain

• Understanding aetiology and pathogenesis of Pain.

• Taking history to arrive TENTATIVE DIFFERENTIAL DIAGNOSIS.

• Making physical examination to reach WORKING DIAGNOSIS.

• Plan the management based upon the working diagnosis.

10 Features of pain

• site (ask the patient to point with one finger; has the site of pain changed?)

• severity (compared to previous experiences)• characteristics (e.g. sharp, burning, gnawing, dull)• radiation (e.g. to back, around abdominal wall into

groin)• onset (e.g. sudden, gradual, time of day)• periodicity (over minutes, hours)

• relieving factors (e.g. movement, vomiting, lying still, leaning forwards)

• exacerbating factors (e.g. movement, drinking fluids)

• associated features (e.g. nausea, vomiting, changes in colour of urine, stool or skin)

• previous episodes (hours/days/weeks/years ago; more/less severe; diagnosis then?)

Beware: -pain perceived to be in the abdomen may be referred to the upper abdomen from organs superior to the diaphragm, particularly the heart (e.g. with angina or myocardial infarction) or the lung and pleurae (e.g. in pneumonia, lung infarction)

Pathways of visceral innervation.

The afferent fibers mediating pain travel with the autonomic neurons to communicate with the central nervous system where pain is perceived. The vagal and pelvic nerves are parasympathetic fibers, whereas those from the thoracic and lumbar groups are sympathetic.

Neuroanatomic pathway mediating visceral pain.

The pathway from sensation in an abdominal viscus to perception of pain in the thalamus, somatosensory cortex, limbic system and frontal lobes.

CLINICAL HISTORY

A complete clinical history with an open mind, the history in their own words, and examiners should refrain from suggesting specific symptoms, except as a last resort. Any questions that must be asked should be open-ended for example,

“What happens when you eat?”

rather than

“Does eating make the pain worse?”

Leading questions should be avoided. When a leading question must be asked, it should be posed first as a negative question (i.e., one that calls for an answer in the negative), since a negative answer to a question is more likely to be honest and accurate. For example, if peritoneal inflammation is suspected, the question asked should be

“Does coughing make the pain better?” rather than

“Does coughing make the pain worse?”

Mode of onset of PAIN

• A sudden onset an intra-abdominal catastrophe,

– a ruptured abdominal aortic aneurysm, – a perforated viscus, or – a ruptured ectopic pregnancy.

Rapidly progressive pain that becomes intensely centered in a well-defined area within a period of a few minutes to an hour or two – acute cholecystitis, pancreatitis, or mesenteric

thrombosis.

• A gradual onset over several hours, usually beginning as slight or vague discomfort and slowly progressing to steady and more localized pain - subacute process ( characteristic of peritoneal inflammation. )– acute appendicitis, – diverticulitis, – pelvic inflammatory disease (PID),– incarcerated hernias, and intestinal obstruction.

Disorders associated with diffuse abdominal painIn most disorders that give rise to acute abdominal pain, the pain tends to occur inspecific locations. This diagram shows causes of diffuse pain

DIFFUSEPeritonitis

Early AppendicitisPancreatitisLeukemia

Sickle Cell CrisisGastroenteritis

Mesenteric AdenitisMesenteric ThrombosisIntestinal Obstruction

Inflammatory Bowel DiseaseAneurysm

Metabolic CausesToxic Causes

Disorders associated with acute pain in the umbilical and hypogastric regionsListed here are disorders which may cause pain in the umbilical and hypogastric regions

EPIGASTRIC REGIONPeptic Ulcer

GastritisPancreatitisDuodenitis

GastroenteritisEarly appendicitis

Mesenteric adenitisMesenteric thrombosis

Intestinal obstructionInflammatory bowel disease

AneurysmHYPOGASTRIC REGIONCystitisDiverticulitisAppendicitisProstatismSalpingitisHerniaOvarian Cyst/TorsionEndometriosisEctopic PregnancyNephrolithiasisIntestinal ObstructionInflammatory Bowel DiseaseAbdominal wall haematoma

UMBILICAL REGIONEarly AppendicitisGastroenteritisPancreatitisHerniaMesenteric AdenitisMesenteric ThrombosisIntestinal ObstructionInflammatory Bowel DiseaseAneurysm

Disorders associated with acute pain, by quadrant

RIGHT UPPER QUADRANTCholecystitis

CholedocholithiasisHepatitis

Hepatic AbscessHepatomegaly from

Congestive Heart FailurePeptic UlcerPancreatitis

Retrocecal AppendicitisPyelonephritis

NephrolithiasisHerpes Zoster

Myocardial IschaemiaPericarditisPneumonia

EmpyemaGastritis

DuodenitisIntestinal obstruction

Inflammatory bowel disease

RIGHT LOWER QUADRANTAppendicitis

Intestinal ObstructionInflammatory Bowel

DiseaseMesenteric Adenitis

DiverticulitisCholecystitis

Perforated UlcerLeaking Aneurysm

Abdominal Wall Haematoma

Ectopic PregnancyOvarian Cyst torsion

SalpingitisMittelschmerzEndometriosis

Ureteral CalculiPyelonephritis

NephrolithiasisSeminal Vesiculitis

Psoas AbscessHernia

LEFT UPPER QUADRANTGastritisPancreatitisSplenic EnlargementSplenic RuptureSplenic InfarctionSplenic AneurysmPyelonephritisNephrolithiasisHerpes ZosterMyocardial IschemiaPenumoniaEmpyema DiverticulosisIntestinal ObstructionInflammatory Bowel Disease

LEFT LOWER QUADRANTDiverticulitisIntestinal ObstructionInflammatory Bowel DiseaseAppendicitisLeaking AneurysmAbdominal Wall HaematomaEctopic PregnancyMittelschmerzOvarian Cyst/TorsionSalpingitisEndometriosisUreteral CalculiPyelonephritisNephrolithiasisSeminal VesiculitisPsoas AbscessHernia

Pain either intermittent or continuous.

Intermittent or cramping pain (colic)

– pain that occurs for a short period (a few minutes), followed by longer periods (a few minutes to one-half hour) of complete remission during which there is no pain at all.

– obstruction of a hollow viscus and results from vigorous peristalsis in the wall of the viscus proximal to the site of obstruction.

– perceived as deep in the abdomen and is poorly localized. The patient is restless, may writhe about incessantly in an effort to find a comfortable position, and often presses on the abdominal wall in an attempt to alleviate the pain.

• the intermittent pain associated with intestinal obstruction typically described as gripping and mounting is usually severe but bearable

• the pain associated with obstruction of small conduits (e.g., the biliary tract, the ureters, and the uterine tubes) often becomes unbearable.

• Obstruction of the gallbladder or bile ducts gives rise to a type of pain often referred to as biliary colic; (a misnomer, in that biliary pain is usually constant because of the lack of a strong muscular coat in the biliary tree and the absence of regular peristalsis.)

Continuous or constant pain present for hours or days without anyperiod of complete relief usually indicativeof peritoneal Inflammation or ischemia. Itmay be of steady intensity throughout, or itmay be associated with intermittent pain.

The typical colicky pain associated with simple intestinal obstruction changes when strangulation occurs, becoming continuous pain that persists between episodes or waves of cramping pain.

Typical of certain pathological states–• the general burning pain of a perforated gastric ulcer,

• the tearing pain of a dissecting aneurysm, and• the gripping pain of intestinal obstruction.

The character of the pain is not always a reliable clue to its cause. For several reasons–atypical pain patterns, dual innervation by visceral and somatic afferents, normal variations in organ position, and widely diverse underlying pathological states–the location of abdominal pain is only a rough guide to diagnosis.

• nevertheless the pain tends to occur in characteristic locations, such as the right upper quadrant (cholecystitis), the right lower quadrant (appendicitis), the epigastrium (pancreatitis), or the left lower quadrant (sigmoid diverticulitis)

Important to determine the location of the pain at onset because this may differ from the location at the time of presentation (so-called shifting pain).

In fact, the chronological sequence of events in the patient’s history is often more important for diagnosis than the location of the pain alone.

the classic pain of appendicitis begins in the periumbilical region and settles in the right lower quadrant.

Fluid tracing down the right paracolic gutter explains how the SS of a perforated DU can be referred to RIF

A similar shift in location can occur when escaping gastroduodenal contents from a perforated ulcer pool in the right lower quadrant.

Locations for pain related to conditions causing an acute abdomen.

Biliary colic may radiate to the back or shoulder (dotted line).

Patterns of referral of pain of abdominal origin: anteriorPain of abdominal origin tends to be referred in characteristic patterns. The moresevere the pain is, the more likely it is to be referred. Shown are the anterior areasof referred pain

Oesophagus

Stomach

Liver andGallbladder

Pylorus

ColonLeft and Right

Kidneys

Ureter

Patterns of referral of pain of abdominal origin: posteriorPain of abdominal origin tends to be referred in characteristic patterns. The more severe the pain is, the more likely it is to be referred. Shown are the posterior areas of referred pain

Uterine and Rectal Pain

Acute Pancreatitis and

Renal colic

Biliary Colic

Perforated Duodenal Ulcer(Diaphragmatic Irritation)

Radiation or referral of the pain -biliary pain is referred to the right subscapular area, and the boring pain of pancreatitis typically radiates straight through to the back.

The more severe the pain is, the more likely it is to be referred.

The intensity or severity of the pain is related to the magnitude of the underlying insult. significant interethnic and intercultural differences with respect to tolerance of and reaction to pain.

• Pain - intense enough to awaken the patient from sleep a significant underlying organic cause.

• Past episodes of pain and factors that aggravate or relieve the pain often provide useful diagnostic clues.

• Pain caused by peritonitis tends to be exacerbated by motion, deep breathing, coughing, or sneezing, and patients with peritonitis tend to lie quietly in bed and avoid any movement.

Acute pancreatitis is exacerbated by lying down and relieved by sitting up.

TYPICAL PAIN

In acute pancreatitis, to gain some measure of relief, sits up and leans forward or on the side in the knee-chest position

Pain that is relieved by eating or taking antacids suggests duodenal ulcer disease,

Diffuse abdominal pain that appears one half to one hour after meals suggests intestinal angina.

Associated gastrointestinal symptoms

• nausea, vomiting, anorexia, diarrhea, and constipation, (nonspecific) {not of great value in the differential diagnosis.}

• Vomiting with acute appendicitis, in whom pain almost always precedes vomiting by several hours.

Constipation (reflex paralytic ileus when sufficiently stimulated visceral afferent fibers activate efferent sympathetic fibers (splanchnic nerves) to reduce intestinal peristalsis.)

Diarrhea (gastroenteritis) but may also accompany incomplete intestinal obstruction. Obstipation, patient with acute abdominal pain has not passed gas or stool for 24 to 48 hours, it is certain that some degree of intestinal obstruction is present. Other - jaundice, melena, hematochezia, hematemesis, and hematuria. (much more specific)

Most conditions that cause acute abdominal pain of surgical significance are associated with some degree of fever. Fever suggests an inflammatory process; usually low grade and often absent altogether, particularly in elderly and immunocompromised patients.

• Combination of a high fever with chills and rigors indicates bacteremia, and

• Concomitant changes in mental status (e.g., agitation, disorientation, and lethargy) suggest impending septic shock.

• A history of trauma (even if the patient considers the traumatic event trivial) should be actively sought in all cases of unexplained acute abdominal pain; such a history may not be readily volunteered (as is often the case with trauma resulting from domestic violence).

Female patients-timing of symptoms within the menstrual cycle, -the date of the last menses, -previous and current use of contraception, -any abnormal vaginal bleeding or discharge, -an obstetric history, and -any risk factors for ectopic pregnancy (e.g., PID, use of an intrauterine device, or previous ectopic or tubal surgery).

• A complete history of previous medical conditions cardiac, pulmonary, and renal systems may give rise to acute abdominal symptoms and may also significantly affect the morbidity and mortality associated with surgical intervention.

• Weight changes, past illnesses, recent travel, environmental exposure to toxins or infectious agents, and medications used should also be investigated.

• A history of previous abdominal operations should be obtained but should not be relied on too heavily in the absence of operative reports.

• A careful family history for detection of hereditary disorders that may cause acute abdominal pain. A detailed social history should also be obtained that includes tobacco, alcohol, or illicit drug use as well as a sexual history.

Tentative Differential Diagnosis

• The most common diagnosis in these patients was nonspecific abdominal pain (NSAP)–(the retrospective diagnosis of exclusion in which no cause for the pain can be identified.)

• the four most common diagnoses accounted for more than 75 percent. The most common surgical diagnosis - acute appendicitis,

- acute cholecystitis, - small bowel obstruction, and - gynecologic disorders.

The disease spectrum of acute abdominal pain is different in different age groups, especially in the very old and the very young. 50 years of age or older, cholecystitis was more common than either NSAP or acute appendicitis.

• Small bowel obstruction, diverticular disease, and pancreatitis were all approximately five times more common than in patients younger than 50 years.

• Hernias were also a much more common problem in older patients.

• Cancer was 40 times more likely to be the cause of acute abdominal pain in patients 50 years of age or older.

Vascular diseases (including myocardial infarction, mesenteric ischemia, and ruptured abdominal aortic aneurysm) were 25 times more common in patients 50 years of age or older and 100 times more common in patients older than 70 years.

• What is more, outcome was clearly related to age: mortality was significantly higher in patients older than 70 years (five percent) than in those younger than 50 years (less than one percent).

• Well over 90 percent of cases of acute abdominal pain in children are diagnosed as either acute appendicitis (23 percent) or nonspecific abdominal pain (26 percent)

• thinly

ABDOMINAL PAINVISCERAL PAIN PARIETAL PAIN

C FIBRESAUTONOMIC

INJURY TO ORGAN /ADHERENT

PERITONEUM

DISTENSION, STRETCH, TRACTION, COMPRESSION, TORSION, ISCHEMIA, AND

INFLAMMATION

INSENSATE TO HEAT, CUTTING, OR ELECTRICAL

STIMULATION

UNMYELINATED, POLYMODAL

NOCICEPTORS THAT CONDUCT SLOWLY (0.5–5

M/S) PRODUCING A DULL, CRAMPY

PAIN

BILATERALLY WITH THE SYMPATHETIC AND

PARASYMPATHETIC CHAINS, VAGUE, CENTRAL ABDOMINAL PAIN

A SOMATIC FIBERS

COURSING WITH THE SPINAL NERVES T7

THROUGH L2

MYELINATED, FAST

CONDUCTORS SHARP, PRICKING

PAINPERITONITIS

SEVERELOCALIZED

REFERRED +/-ASS. WITH

REBOUND/RIGIDITY

RIGIDITY IS VOLUNTARILY OVERCOME BY THE PATIENT

VOLUNTARY GUARDING. INVOLUNTARY GUARDING OMINOUS,

DIFFUSE PERITONITIS

History and Physical Exam

• Onset and associated activities• changes in bowel habits• color and consistency of vomitus and stool• associated constitutional symptoms (weight loss,

fever, anorexia) • prior medical problems or surgery• mask symptoms • Age, family history, alcohol and drug use, and

menstrual history

most urgent and devastating cause of acute abdomen is a ruptured aortic aneurysm and should be considered in any

unstable patient

• stable patient hydration status (dry mucous membranes, poor skin turgor, slow capillary refill, pale skin, or conjunctiva), as well as the patient’s comfortlevel (writhing suggests colicky pain, whereas a patient with diffuse peritonitis will lie very still).

• Inspect the abdomen for distension, surgical scars, organomegaly, asymmetry from mass effect, varices, and respiratory variation

• retroperitoneum can be indirectly examined via the obturator (flexed external rotation of the thigh) and psoas (extension of the leg) maneuvers

• Rectal exam for fissures and fistulas, pelvic masses, stool and fecal impaction, gross or occult blood

Diagnostic Testing.

• Nonspecific - presence of infection (leukocytosis) or anemia

• Electrolyte and hydration status in the patient with vomiting, diarrhea, or prolonged anorexia

• Urinalysis urinary tract infection or isolated pyuria

• Transaminases,• alkaline phosphatase, bilirubin, amylase, and

lipase

• Chest roentgenogram – for pneumonia, free air suggesting viscus perforation,

• Abdominal X-ray Bowel wall edema, fecoliths, air-fluid levels, bowel gas pattern, and dilation suggesting obstruction or volvulus and occasionally biliary and renal calculi can also be seen on abdominal films.

• Ultrasound- cholecystitis, biliary dilation or stones, hepatic masses, hydronephrosis, or renal calculi

• Urine or serum HCG level should be determined for every woman of childbearing age, and ectopic pregnancy considered high in the differential diagnosis until proven otherwise

• Computed tomography, upper and lower contrast studies - unless specific disease processes

• Pancreatitis, diverticulitis, and abscess are evaluated well by CT scan

• Diverticular disease, inflammatory bowel disease, ulcer disease, and malignancies can be evaluated by contrast studies.

• key importance is recognition of the need for early surgical intervention

• A diagnosis is not necessary before deciding to• operate and a lengthy work-up that can

potentially delay treatment should be avoided• diagnostic laparoscopy or laparotomy should

always be considered if catastrophic processes (i.e., ischemic bowel, appendicitis)

• negative laparotomy is never a morbidity

Mastering the sleuth of the history and physical, the efficiency of choosing an appropriate and focused work-up, and

the expeditious resuscitation and ultimate treatment is the art of acute

management of abdominal pain.

DIFFERENTIAL DIAGNOSIS

Generalized Pain ~Intestinal infarction, peritoniit, obstruction, diabetic ketoacidosis, sickle crisis, acute porphyria, penetrating posterior ulcer, psychogenic pain

RUQ ~Cholecystitis, cholangitis, hepatitis, gastritis, pancreatitis, hepatic metastases, gonococcal perihepatitis, retrocaecal appendicitis, pneumonia, peptic ulcer

DIFFERENTIAL DIAGNOSIS

Epigastrium ~Gastritis, Peptic ulcer, GERD, Oesophagitis, GE, Pancreatitis, Perforated viscus, Intestinal obstruction, ileus, myocardial infarction, aortic aneurysm

LUQ ~Peptic ulcer, Gastritis, Oesophagitis, GERD, Pancreatitis, Myocardial ischaemia, Pneumonia, Splenic infarction, pulmonary embolus

LLQ ~Diverticulitis, Intestinal Obstruction, Colitis, Strangulated hernia, Infl. Bowel disease, GE, Pyelonephritis, Nephrolithiasis, Mesenteric lymphadenitis, Mesenteric thrombosis, Aortic aneurysm, Volvulus, Intussusception, Sickle crisis, Salpingitis, Ovarian Cyst, Ectopic pregnancy, Endometriosis, Testicular torsion, Psychogenic pain

RLQ ~Appendicitis, diverticulitis (redundant sigmoid), Salpingitis, Endometritis, Endometriosis, Intussusception, Ectopic pregnancy, Haemorrhage or rupture of ovarian cyst, renal calculus

Hypogastric/Pelvis~Cystitis, Salpingitis, Ectopic Pregnancy, Diverticulitis, Strangulated hernia, Endometriosis, Appendicitis, Ovarian Cyst torsion, Bladder distension, Nephrolithiasis, Prostatitis, Malignancy

PHYCISCAL EXAMINATION

in search of specific signs or findings that either rule out or confirm

• There is no substitute for organization and

patience; as in history taking the amount of information that can be obtained is directly proportional to the gentleness and thoroughness of the examiner.

• a brief but thorough evaluation of the patient’s general appearance and ability to answer questions.

• The degree of obvious pain should be estimated.

• The patient’s position in bed a patient who lies motionless with flexed hips and knees likely to have generalized peritonitis

• A restless patient who writhes about in bed is more likely to have colicky pain

• The area of maximal pain should be identified before the physical examination is begun simply asking the patient to cough and then to point with one finger to the area of maximal pain.

• The absence of any alteration in vital signs, however, does not necessarily exclude a serious intra-abdominal process.

• The examination should include inspection, palpation, percussion, and auscultation of all areas of the abdomen, the flanks, and the groin (including all hernia orifices) rectal and genital examinations.

INSPECTION the anterior and posterior abdominal walls, the flanks, the perineum, and the genitalia for previous surgical scars (possible adhesions), hernias (incarceration or strangulation),distention (intestinal obstruction),obvious masses (distended gallbladder, abscesses, or tumors), ecchymosis or abrasions (trauma),

• striae (pregnancy or ascites), • everted umbilicus (increased intra-

abdominal pressure),• visible pulsations (aneurysm),• visible peristalsis (obstruction), • limitation of movement of the abdominal wall

with ventilatory movements (peritonitis), orengorged veins (portal hypertension).

Visible peristalsis - ladder pattern. Irreducible right femoral hernia +

In volvulus of the sigmoid colon, owing to the length of mesentery, the swelling is 1st seen in Right iliac fossa

Leaking AAA taken in OT preoperatively

Leaking AAA in an 80-year old man; blood tracked into the sub-cutaneous tissue from clot in the LIF

PALPATION (most informative)

Very gently to avoid causing additional pain early in the examination. begin as far as possible from the area of maximal pain and then should gradually advance toward this area, which should be the last to be palpated.

To determine whether true involuntary muscle guarding (muscle spasm) is present by means of gentle palpation over the abdominal wall while the patient takes a long, deep breath.

• If guarding is voluntary, the underlying muscle immediately relaxes under the gentle pressure of the palpating hand. If, however, the patient has true involuntary guarding, the muscle remains in spasm (i.e., taut and rigid) throughout the respiratory cycle (so-called board-like abdomen).

• True involuntary guarding localized or generalized peritonitis. (muscle rigidity is relative, less pronounced or absent in debilitated and elderly patients.)

• Dependent on the patient’s cooperation. • Diffuse tenderness indicates generalized

peritoneal inflammation.

• Mild diffuse tenderness without guarding usually indicates gastroenteritis or some other inflammatory intestinal process without peritoneal inflammation.

• Localized tenderness suggests an early stage of disease with limited peritoneal inflammation.

• Two cardinal signs of intraperitoneal inflammation are rigidity of the abdominal wall (reflex contraction of the abdominal wall muscles at rest) and guarding (provocation from the pressure of the examining hand).

• Signs of peritoneal irritation - extreme tenderness, rebound tenderness, voluntary guarding, motion pain (on moving, pelvic rocking, moving of stretcher or heel strike), involuntary guarding/rigidity (late)

Where it starts?

Where is the pain now?

•The pointing sign - site of maximum pain (if it is also the site of maximum tenderness ~ the underling viscus is very likely to be the site of the problem.

McBurney’s point

Point of maximum tenderness in retrocaecal appendicitis

Point of tenderness in maldescent of caecum

• The cough test - If asked to cough – Pain in abdomen – inflammation of parietal peritoneum; pain in chest – inflammation of parietal pleura.

• Bed shaking test (Bapat’s sign)- in the presence of peritoneal inflammation – pain at the site of inflammation.

• Rebound tenderness (Blumberg’s sign) - Release sign (resurgence of pain as the examiner’s hand is withdrawn sharply after deep palpation) if there is doubt about the possibility of early peritonitis – not used if obvious tenderness already exists.

Exert deep pressure at the site of pain

Remove the hand suddenly

Fingertip pressure over McBurney’s point in a child

Palpating the abdomen with the child’s own hand

•Percussion rebound - gentle percussion is sufficient to identify and localize severe inflammation without the need for potentially painful palpation – valuable in children.

Specific signs • Rovsing’s sign (associated with acute

appendicitis) • Murphy’s sign (acute cholecystitis)–that are

indicative of localized peritoneal inflammation.

• the psoas sign (associated with retrocecal appendicitis), the obturator sign (pelvic appendicitis).

• Kehr’s sign (diaphragmatic irritation). • Carnett’s test, in which the patient elevates his or

her head off the bed, thus tensing the abdominal muscles. Tenderness to palpation persists when the pain is caused by abdominal wall conditions (e.g., rectal sheath hematoma) but decreases or disappears when the pain is caused by intraperitoneal conditions (Carnett’s sign).

Rectal examinations sphincter tone, tenderness (localized versus diffuse), and prostate size and tenderness, as well as a search for the presence of hemorrhoids, masses, fecal impaction, foreign bodies, and gross or occult blood.

Genital examination adenopathy, masses, discoloration, edema, and crepitus.

Pelvic examination • vaginal discharge or bleeding• Cervical discharge or bleeding, cervical mobility and

tenderness • Uterine tenderness, uterine size, and adnexal

tenderness or masses. • Although a carefully performed pelvic examination

can be invaluable in differentiating nonsurgical conditions (e.g., PID) from conditions necessitating prompt operation (e.g., acute appendicitis)

The possibility that a surgical condition is present should not be prematurely dismissed solely on the basis of a finding of tenderness on pelvic or rectal examination.

PERCUSSION• search for any areas of dullness, fluid

collections, sections of gas-filled bowel, or pockets of free air under the abdominal wall.

• Tympany may be present in patients with bowel obstruction or hollow viscus perforation.

• estimating organ size and of determining the presence of it is most useful, however,

• a means of demonstrating peritoneal irritation (rebound tenderness).

• The customary technique is to dig the fingers deep into the patient’s abdomen and then let go abruptly.

Gentle percussion over the four quadrants of the abdomen is much better tolerated by the patient; in addition, it is much more accurate in demonstrating rebound tenderness (which, incidentally, can also be easily accomplished by simply having the patient cough–so-called cough tenderness).

AUSCULTATION Note the presence (or

absence) of bowel sounds and their quality.

Severe intra-abdominal conditions, even intra-abdominal catastrophes, may occur in patients with normal bowel sounds, and patients with silent abdomens may have no significant intra-abdominal pathology at all.

In general, however, the absence of bowel sounds indicates a paralytic ileus; hyperactive or hypoactive bowel sounds often are variations of normal activity; and high-pitched bowel sounds with splashes, tinkles (echoing as in a large cavern), or rushes (prolonged, loud gurgles) indicate mechanical bowel obstruction.

Pitfalls• A small inguinal or femoral

hernia causing intestinal obstruction may be overlooked because all attention is focused on the abdominal signs and symptoms.

• Failure to perform a digital rectal examination may mean missing important pathology in the anorectum and pelvis, remembering that impaction of faeces is one of the commoner causes of intestinal obstruction.

In intestinal obstruction, the abdomen should be uncovered from the nipple to the apex of femoral triangle – small irreducible hernia can be missed

• Failure to carry out a vaginal examination may miss the opportunity to diagnose gynaecological and other pelvic disease.

• Finally, failure to examine the chest may miss causes of referred abdominal pain such as basal pneumonia.

ESTABLISHING A DIAGNOSIS • The history and physical examination are

followed attempt to define the nature of the disease and the organ/system involved. A working diagnosis is made, a differential diagnosis constructed, and the need for further investigations is defined.

LABORATORY STUDIES In all except extremely hemodynamically

unstable patients - a complete blood

count, blood chemistries, and a urinalysis The hematocrit ~ changes in plasma volume (e.g., dehydration caused by vomiting, diarrhea, or fluid loss into the peritoneum or the intestinal lumen), preexisting anemia, or bleeding.

An elevated white blood cell count is indicative of an inflammatory process and is a particularly helpful finding if associated with a marked left shift; however, the presence or absence of leukocytosis should never be the single deciding factor as to whether the patient should undergo an operation. A low white blood cell count may be a feature of viral infections, gastroenteritis, or NSAP.

Serum electrolyte, blood urea nitrogen, and creatinine concentrations are useful in determining the nature and extent of fluid losses. Blood glucose and other blood chemistries may also be helpful. Liver function tests (serum bilirubin, alkaline phosphatase, and transaminase levels) are mandatory when abdominal pain is suspected to be hepatobiliary in origin.

Amylase and lipase determinations are mandatory when pancreatitis is suspected, although it must be remembered that amylase levels may be low or normal in patients with pancreatitis and may be markedly elevated in patients with other conditions (e.g., intestinal obstruction, mesenteric thrombosis, and perforated ulcer).

Urinalysis red blood cells (suggestive of renal or ureteral calculi)white blood cells (urinary tract infection or inflammatory processes adjacent to the ureters, such as retrocecal appendicitis) increased specific gravity (dehydration), glucose, ketones (diabetes), bilirubin (hepatitis).

ECGMandatory in elderly patients and in patients with a history of atherosclerotic heart disease. Abdominal pain may be a manifestation of myocardial disease.The physiologic stress of acute abdominal pain can increase myocardial oxygen demands and induce ischemia in patients with coronary artery disease.

RADIOLOGIC STUDIES

In all except hemodynamically unstable patients, initial radiologic evaluation should include plain films of the abdomen in the supine and standing positions and chest radiographs.If the patient is unable to stand, a left lateral decubitus radiograph should be obtained.

Free peritoneal air (arrow) under the diaphragm on an upright chest radiograph.

Upright abdominal radiograph showing air-fluid levels (arrows).

Small bowel obstruction. (a) Radiograph showing abdominal distension, dilated loops of small bowel and a paucity of colonic gas.

Radiographic findings in sigmoid and cecal volvulus. (Top) There is abdominal distension, a large gas-filled sigmoid colon and a 'beak' in the left lower quadrant. (Bottom) There is abdominal distension, a large-gas filled cecum and a 'beak' in the right lower quadrant.

These plain radiographs may help, confirm diagnoses such as

• pneumonia (signaled by pulmonary infiltrates);• intestinal obstruction (air-fluid levels and dilated

loops of bowel); • intestinal perforation (pneumoperitoneum); • biliary, renal, or ureteral calculi (abnormal

calcifications);• appendicitis (fecalith); • incarcerated hernia (bowel protruding beyond the

confines of the peritoneal cavity);

• mesenteric infarction (air in the portal vein); • chronic pancreatitis (pancreatic calcifications); • acute pancreatitis (the so-called colon cutoff sign);• visceral aneurysms (calcified rim); • retroperitoneal hematoma or abscess (obliteration

of the psoas shadow); and • ischemic colitis (so-called thumbprinting on the

colonic wall).

Ultrasounds of the right upper quadrant. (a) Normal gallbladder without stones.

(b) Gallbladder containing stones (arrow), as demonstrated by sonographic echogenicity, the thickened gallbladder wall and pericholecystic fluid.

HIDA scans - normal and in cystic duct obstruction. (a) 'Normal' demonstrating hepatic uptake, excretion into the right and left hepatic ducts, the common hepatic duct, the gallbladder (large arrow), the common bile duct (arrowhead) and the duodenum (small arrow).

Patient who has cystic duct obstruction secondary to acute cholecystitis.

Acute perforation due to diverticulitis. There is an extraluminal fluid collection (white arrow), and fat streaking (black arrow).

WORKING DIAGNOSISSubsequent management depends on the accepted treatment for the particular condition believed to be present.

In general, the course of management follows four basic pathways, depending on whether the patient

(1) is in need of immediate laparotomy, (2) is believed to have an underlying surgical condition, (3) has an uncertain diagnosis, or (4) is believed to have an underlying

nonsurgical condition.

CONSTANTLY RE-EVALUATED (PREFERABLY BY THE SAME EXAMINER) EVEN AFTER THE WORKING DIAGNOSIS HAS BEEN ESTABLISHED.

Suspected Non-surgical Abdomen

The acute abdominal pain of lead poisoning or acute porphyria (marked hyperperistalsis), acute and prostrating abdominal pain accompanied by rigidity of the abdominal wall and a low hematocrit may lead to unnecessary urgent laparotomy in patients with sickle cell anemia crises with/out cholelithiasis.

Non-surgical causes of abdominal pain

CardiaMyocardial infarctionAcute pericarditis

PulmonaryPneumonia Pulmonary infarction Gastrointestinal Acute pancreatitis Gastroenteritis Acute hepatitis

Endocrine Diabetic ketoacidosis Acute adrenal insufficiency

MetaboclicAcute porphyria Familial Mediterranean fever Hyperlipidemia MusculoskeletaReRectus muscle hematoma

Central and peripheral nervous system Tabes dorsalis Nerve root compression

Genitourinary Pyelonephritis Acute salpingitis

Hematologic Sickle cell crisis

• Knowledge of the most common causes of acute abdominal pain and familiarity with the special circumstances that make particular causes more likely than others allow the practitioner to play the odds.

• As has often been said, – common things are common–or, – to put it another way,

most people get what most people get.

A pregnancy test should be considered in any woman of childbearing age with acute abdominal pain.

History/PE

Diagnostic tests choice determined by location of pain and more likely

dx at that site

TREAT

HAEMODYNAMICALLY STABLE

no

Suspected ruptured AAA

YES

Resuscitation & Urgent Surgery

YES

No

RIGID ABD

CXR/ABD X’ray

Perforation/ Obstruction

Resus-citation

& Urgent Surgery

NONon-

specific

INVESTIGATION, OPERATE

PROMPTLY IF FAILS TO IMPROVE

ACUTE ABDOMINAL

PAINAbdominal

regions

A systematic approach is crucial:

an examiner who methodically follows a

set pattern of abdominal examination every time will be rewarded more

frequently than one who improvises haphazardly

with each patient.

“Customers are the most important visitors on our premises.

They are not dependent on us. We are dependent on them.

They are not an interruption on our work. They are the purpose of it.

They are not an outsider in our business. They are part of it.

We are not doing them a favour by serving them. They are doing us a favour by giving us an opportunity to do so.”

Mahatama Gandhi